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Clinical Policy Title: Blepharoplasty
Clinical Policy Number: 10.03.01
Effective Date: July 1, 2013
Initial Review Date: June 19, 2013
Most Recent Review Date: May 1, 2018
Next Review Date: May 2019
Related policies:
None.
ABOUT THIS POLICY: AmeriHealth Caritas has developed clinical policies to assist with making coverage determinations. AmeriHealth Caritas’ clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of “medically necessary,” and the specific facts of the particular situation are considered by AmeriHealth Caritas when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. AmeriHealth Caritas’ clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. AmeriHealth Caritas’ clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, AmeriHealth Caritas will update its clinical policies as necessary. AmeriHealth Caritas’ clinical policies are not guarantees of payment.
Coverage policy
AmeriHealth Caritas considers the use of blepharoplasty to be clinically proven and, therefore, medically
necessary when the following criteria are met, as per the Center for Medicare & Medicaid Services [CMS]
local coverage determinations and medical policy article A52847 listed below:
Criteria for medical necessity
Upper eyelid reconstructive blepharoplasty (current procedural terminology
[CPT] codes 15822, 15823) is considered medically necessary for correction of
functional visual impairment due to any of the following indications:
o Dermatochalasis, blepharochalasis, or blepharoptosis with visual field
impairment, whether in primary gaze or down-gaze reading position.
o Ptosis or prosthesis difficulties in an anophthalmic socket.
o Epiphora (i.e., excessive tearing) due to ectropion and/or punctual eversion.
o Painful blepharospasm when debilitating and other treatments have failed or
are contraindicated (i.e., an injection of botulinum toxin A); an extended
Policy contains:
Cosmetic blepharoplasty.
Eyelid surgery.
Ptosis.
Reconstructive blepharoplasty.
3
Criteria for medical necessity
blepharoplasty with wide resection of the orbicularis oculi muscle complex
may be necessary.
o Orbital sequelae of thyroid disease or nerve palsy (e.g., exposure keratitis).
o Upper eyelid defect caused by trauma, tumor, or ablative surgery resulting in
a severe physical deformity or disfigurement, which is causing functional
visual impairment as confirmed by preoperative frontal photographs.
o Congenital ptosis when needed to allow proper visual development and
prevent amblyopia in infants and children with moderate to severe ptosis
interfering with vision. Surgery is considered cosmetic if performed for mild
ptosis that is only of cosmetic concern. Photographs must be available for
review to document that the skin or upper eyelid margin obstructs a portion
of the pupil.
Lower lid blepharoplasty (CPT codes 15820 and 15821) is considered medically
necessary for correction of functional visual impairment due to any of the
following indications:
o Horizontal lower eyelid laxity of medial and lateral canthus resulting in
dacryostenosis and infection.
o Significant lower eyelid edema.
o When glasses rest upon the lower eyelid tissues and cause lower eyelid
ectropion as a result of the weight of the glasses and weight of the tissue.
Combination of blepharoplasty, blepharoptosis repair, and/or brow lift is
considered medically necessary when the medical necessity criteria for each
procedure are met and both of the following additional criteria are met:
o Visual field testing demonstrates visual impairment that cannot be addressed
by one procedure alone.
o Lateral and full face photographs with attempts at 1) brow elevation and 2)
upward gaze (i.e., with the brow relaxed) support the request.
Required documentation
(Must meet requirements from sections A, B, and C below)
A. Patient signs and symptoms which justify blepharoplasty may include any of the
following:
o Interference with vision or visual field, related to activities such as, difficulty
reading due to upper eyelid drooping, looking through the eyelashes, seeing
the upper eyelid skin, or brow fatigue.
o Chronic eyelid dermatitis due to redundant skin.
o Difficulty wearing prosthesis.
o Chronic blepharitis.
4
Required documentation
(Must meet requirements from sections A, B, and C below)
B. Photographs and medical documentation of indications causing malpositioning of
the eyelid(s). Also may include:
o Margin reflex distance (MRD) of ≤ 2.5 mm; the upper eyelid margin
approaches to within 2.5 mm (1/4 of the diameter of the visible iris) of the
corneal light reflex.
o A palpebral fissure height on down-gaze of ≤ 1 mm. The down-gaze palpebral
fissure height is measured with the patient fixating on an object in down-gaze
with the ipsilateral brow relaxed and the contralateral lid elevated).
o The presence of Herring's effect meeting one of the above two criteria.
C. Visual fields testing must do all of the following:
o Demonstrate a minimum 12° or 30 percent loss of upper field of vision with
upper lid skin and/or upper lid margin in repose and elevated (by taping of
the lid) to demonstrate potential correction by the proposed procedure or
procedures.
o Meet accepted quality standards, whether they are performed by Goldmann
technique or by use of a standardized automated technique.
o Visual field testing is not necessary for:
1. Patients with an anophtholmic socket who is experiencing ptosis or
difficulty with their prosthesis.
2. Patients who are not capable of performing the testing, for example:
a. Child 12 years old or under.
b. Patient with mental retardation or some other severe neurologic
disease.
c. Coverage will be determined on the basis of clinical notes
documenting eyelid abnormality, MRD-1 of ≤ 2.5 mm and photographs
confirming the eyelid abnormality.
Limitations:
All other uses of blepharoplasty are not medically necessary. AmeriHealth Caritas considers blepharoplasty,
performed solely to enhance a patient’s appearance, in the absence of any signs or symptoms of functional
abnormalities, to be not medically necessary for individuals who do not meet the above criteria.
Alternative covered services:
Evaluation by network primary care physicians and eye care professionals.
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Background
Blepharoplasty is a procedure that reconstructs eyelid deformities and improves abnormal function and/or
enhances appearance of the eyelids. It involves the excision of excess skin, muscle or fat from the upper
and lower eyelids and may include rearrangement of the structures with the eyelids and/or tissues of the
cheek, forehead and nasal areas using local or distant tissue grafts to reconstruct the normal structure of
the eyelid. Advances in minimally invasive techniques, including laser-assisted applications, may allow for
greater patient comfort, fewer complications and more rapid recovery (American Society of Plastic
Surgeons [ASPS], 2007a). The annual number of blepharoplasties (for functional reasons) in the U.S. tripled
from 2001 to 2011 (now 136,000 a year), while the cost quadrupled to $80 million a year (Prendiville,
2014).
Blepharoplasty is considered restorative and, therefore, medically necessary when it is performed to
restore significant function to the eyelid that has been altered by trauma, infection, inflammation,
degeneration (e.g., from aging), neoplasia, or developmental defects. Cosmetic blepharoplasty is performed
to improve a patient’s appearance in the absence of any signs and/or symptoms of functional abnormalities
and is not considered medically necessary (ASPS, 2007a).
Patients who may require restorative blepharoplasty present with a variety of symptoms or combination of
symptoms, including edema, visual field defects, hypertrophy of the obicularis oculi, conjunctival
inflammation, keratitis, malar festoons, blepharospasm, blepharochalasis, dermatochalasis, lagophthalmos,
protrusion of orbital fat, eyelid ptosis, and eyebrow ptosis. To assess for ophthalmic and periocular disease,
surgeons look for current illnesses, dry eye, allergies, history of eyelid swelling, thyroid disease, heart
failure, and bleeding tendencies in the medical history.
Contraindications to blepharoplasty include:
Underlying conditions, such as Graves’ disease, that may be related to the development of
conditions that cause visual field loss, as the excessive eye bulk that may result from these
conditions will typically resolve after adequate medical treatment, obviating the need for
surgical intervention.
Untreated thyroid disease.
Conditions associated with dry eye syndrome (e.g., collagen vascular disorders, lupus,
rheumatoid arthritis, or Sjögren’s syndrome).
Active eye disease.
Surgical planning involves several factors, including whether upper or lower eyelids or both will be
surgically treated and the extent of surgical involvement, which technique(s) to use, and any adjunctive
procedures to be performed to restore more complete function or facial expression and for aesthetic
improvement. Adjunctive procedures include brow ptosis repair (internal trans-blepharoplasty, direct,
coronal, or endoscopic), ptosis repair, lacrimal gland suspension, eyelid lengthening and lower eyelid
tightening, or lateral canthopexy (Oestreicher, 2012).
6
Documentation of medical necessity should include indications for reconstructive blepharoplasty, the
severity of the symptoms of eyelid deformities and/or the impact on health-related quality of life. If the
patient is experiencing visual impairment, formal visual field testing by an optometrist or ophthalmologist
may be needed. A complete eye exam may also be appropriate in certain cases. Other diagnostic studies, as
clinically indicated, should be performed and noted, such as Schirmer’s test (tearing or dry eye test),
CBC/BMP, bleeding and clotting studies, and cardiac evaluation. Preoperative photographs may be taken to
meet the requirements of both the insurers and surgeons. Additional photographs may include upward and
downward gaze as well as oblique views (ASPS, 2007a).
Visual field testing is used to measure the severity of eyelid and brow defects. The most significant visual
field measurement associated with determining the need for blepharoplasty is the superior visual field. The
normal extent of the superior visual field is approximately 55° to 60° at the 90° meridian. Impairment of the
superior visual field can range from 20 percent, considered mild ptosis, to 64 percent in more severe cases
where the eyelid crosses the middle of the pupil. In general, mild to moderate impairment of the visual field
is of no clinical significance and requires no intervention. When obstruction of the visual field becomes
severe or significant enough to interfere with the patient's ability to perform activities of daily living,
surgical intervention may be warranted. Generally accepted criteria for clinically significant visual field
impairment are a minimum of at least 20° or 30 percent loss of upper field vision with upper lid skin and/or
upper lid margin in repose and elevated (by taping of the lid) to demonstrate potential correction by the
proposed procedure or procedures (Oestreicher, 2012, ASPS 2007a, ASPS 2007b).
While blepharoplasty is a widely practiced surgical procedure, the potential for complications exists due to
the complex structure and function of the eyelids. Complications range from minor to serious and may be
perceived differently between patient and surgeon. These include superficial ecchymosis and hematoma,
wound dehiscence, scar abnormalities, upper eyelid overcorrection, lower eyelid overcorrection and
retraction, asymmetry, ptosis, epiphora and ocular discomfort, diplopia, ocular injury, orbital hemorrhage
and vision loss, pigmentary abnormalities, and CO2 laser resurfacing. Most complications can be avoided or
mitigated through appropriate patient selection, pre-surgical planning and choice of surgical technique, and
most can be treated effectively (Oestreicher, 2012).
Searches
AmeriHealth Caritas searched PubMed and the following databases:
UK National Health Services Centre for Reviews and Dissemination.
Agency for Healthcare Research and Quality’s National Guideline Clearinghouse and other
evidence-based practice centers.
The Centers for Medicare & Medicaid Services (CMS).
We conducted searches on March 14, 2018. Search terms were: "blepharoplasty" [MeSH].
We included:
Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and
7
greater precision of effect estimation than in smaller primary studies. Systematic reviews use
predetermined transparent methods to minimize bias, effectively treating the review as a
scientific endeavor, and are thus rated highest in evidence-grading hierarchies.
Guidelines based on systematic reviews.
Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple
cost studies), reporting both costs and outcomes — sometimes referred to as efficiency studies
— which also rank near the top of evidence hierarchies.
Findings
The American Society of Plastic Surgeons (ASPS, 2007) and the American Academy of Ophthalmology
(Cahill, 2011) have produced guidelines for blepharoplasty. Evaluating the efficacy of the procedure is
difficult, as the medical literature contains very few randomized controlled studies (RCTs) on the technique
(Chang, 2012).
While the procedure rarely results in major damage to the patient, a survey of 720 American and British
plastic surgeons estimated that permanent and temporary vision loss risk were 1 in 30,000 and 1 in 50,000
procedures, respectively. Hypertension was the greatest risk factor, while retrobulbar hemorrhage was the
main cause of blindness (Mejia, 2011).
A study of 200 patients who underwent blepharoplasty found 32 complications in 19 patients, the
equivalent of 9.5 percent (Patrocinio, 2011). One systematic review compared outcomes of four materials
used in 53 blepharoptosis procedures; it found a range of 87 to 99 percent, 0.6 to 1.9 percent for suture
infections, and 5 to 25 percent for complications (Pacella, 2016).
Side effects from blepharoplasty can be a concern, particularly anesthetic use. One study found that during
the procedure, 2 percent lidocaine injections using a sharp needle had greater average pain than when
using a blunt needle – 5.48 to 4.64 on the visual analog scale of 0 to 10. Bruises or hematomas were found
at 11 of 44 sharp needle sites, compared to 0 of 44 in blunt needle sites (Yu, 2017). Lidocaine with
epinephrine used in anesthesia for blepharoplasty had significantly less pain during anesthetizing than did
prilocaine with felypressin (Pool, 2015b).
Postoperative side effects have also been addressed. A survey of 51 blepharoplasty patients reported
postoperative peak levels for pain (four hours, average 2.45 pills), swelling and bruising (24 hours), and
itching (three days) (Parbhu, 2011). Using a pulsed electromagnetic energy patch made no difference in
post-operative pain, edema, or ecchymosis (Czyz, 2012). Among 38 patients, eyelid cooling failed to reduce
post-operative edema, erythema, hematoma of the eyelids, and pain on the day of surgery, but reduced
pain one day after blepharoplasty (Pool, 2015c).
Some blepharoplasties are performed simultaneously on both eyelids. One study of 127 patients who
underwent the procedure found a significant difference between marginal reflex distance from 1.62 to 3.97
mm before and after surgery, with favorable results and minimal complications (Hu, 2016). Another study
8
of double-eyed blepharoplasty in 51 eyes of 39 patients with aponeurotic ptosis (aging eyelids) concluded
88 percent were successful (Li, 2011).
A Cochrane review of involutional entropion techniques of the lower eyelid identified one RCT with 63
subjects that found the combination of horizontal and vertical eyelid tightening with everting sutures and
lateral tarsal strip was highly curative for entropion compared to vertical tightening with everting sutures
alone in an elderly population (Boboridis, 2011). The authors also noted that the findings were supported
by many good-quality uncontrolled studies on specific surgical procedures that did not meet criteria for
inclusion.
Analyses that capture patient-centered benefits of blepharoplasty can be used to inform future economic
studies. Smith et al. conducted a cross-sectional study to measure self-reported patient benefit derived
from four common oculoplastic procedures using a global quality-of-life scale called the Glasgow benefit
inventory (GBI) (Smith, 2012). The GBI generates a scale from -100 (maximal detriment) through zero (no
change) to +100 (maximal benefit). The total GBI scores for entropion repairs (n = 66), ptosis repairs (n =
50), ectropion repairs (n = 41), and external dacryocystorhinostomies (DCR) (n = 41) were: +25.25 (95
percent CI 20.00-30.50, P < 0.001), +24.89 (95 percent CI 20.04-29.73, P < 0.001), +17.68 (95 percent CI
9.46-25.91, P < 0.001), and +32.25 (95 percent CI 21.47-43.03, P <0.001), respectively, demonstrating a
statistically significant benefit from all procedures.
Policy updates:
In 2017, a total of one guideline/other and nine peer-reviewed references were added to this policy.
In 2018, one peer-reviewed publication was added to the reference list.
Summary of clinical evidence:
Citation Content, Methods, Recommendations
Yu (2017)
Comparison of types of
needles used in
anesthesia
Key points:
RCT of 44 women undergoing bilateral upper blepharoplasty.
Anesthesia 2% lidocaine given with blunt needle in one eyelid, sharp needle in the other.
Bruise/hematoma in 11 women with sharp needle, 0 in blunt needle group.
Mean visual analog scale score higher/worse for sharp needle group (5.45 vs. 4.64).
Hu (2016)
Simultaneous
blepharoplasty
Key points:
Chart review of 127 patients with simultaneous correction of blepharoptosis during double
eyelid blepharoplasty using single-knot continuous non-incisional technique.
Simultaneous correction resulted in significant difference in marginal reflux distance of eyelid
(1.62 to 3.97 mm).
Majority of patients showed favorable outcomes during five-year follow up.
Pool (2015c)
Key points:
9
Citation Content, Methods, Recommendations
Efficacy of eyelid
cooling to reduce post-
op pain and other side
effects
RCT with 38 patients undergoing bilateral blepharoplasty.
One eyelid cooled with an ice pack, one left uncooled, evaluated up to two months.
No difference in pain between groups.
Pain lower in cooled group one day post-op, but not for any other time period.
Chang (2012)
Involutional upper eyelid
ptosis repair techniques
Key points:
Systematic review — No prospective RCT identified.
Systematic review of available observational studies is needed to determine efficacy and
complication rates between different involutional lid ptosis repair techniques.
Czyz (2012)
Recovery using pulsed
electromagnetic energy
after blepharoplasty
Key points:
Randomized, double-blind study of 57 patients with upper blepharoplasty
Patients randomized to a low-level pulsed electromagnetic energy field patch for wound healing
vs. placebo
No difference in patient pain with placebo (1.6) vs. patch (1.3)
Insignificant difference in the two groups for edema (6% less for patch) and ecchymosis (10%
less for patch); significantly less physician-graded erythema for patch group
Patrocino (2011)
Review of complication
rates
Key points:
Retrospective study of 200 patients who underwent transcutaneous blepharoplasty
19 patients had complications (9.5% rate)
Most complications were 12 cases of chemosis, 13 who underwent canthoplasty
Medical treatment performed in 12 patients, revision surgery performed in 7 patients
Borboridis (2011)
Involutional entropion
techniques
Key points:
Cochrane review — one RCT of 63 participants included with eight lost to follow-up.
Combination of horizontal and vertical lower eyelid tightening with everting sutures and lateral
tarsal strip is highly curative for entropion compared to vertical tightening with everting sutures
alone.
Authors noted that results were supported by many good-quality uncontrolled studies on
specific surgical procedures, but the studies did not meet criteria for inclusion.
CMS policies:
Insurer Content
Medicare
Coverage indications, limitations, and/or medical necessity:
A. Upper eyelid blepharoplasty (CPT 15822 and 15823) procedures will be considered
medically necessary when performed as functional/reconstructive surgery to correct:
1. Visual impairment with near or far vision due to dermatochalasis, blepharochalasis or
blepharoptosis; or visual field impairment whether in primary gaze or down-gaze
reading position; or a decrease in peripheral vision and/or upper field vision.
2. Symptomatic redundant skin weighing down on upper lashes.
3. Chronic, symptomatic dermatitis of pretarsal skin caused by redundant upper lid
skin.
4. Ptosis or prosthesis difficulties in an anophthalmic socket.
B. Lower lid blepharoplasty (CPT 15820 and 15821) is considered medically necessary
when documentation:
10
Insurer Content
Supports horizontal lower eyelid laxity of medial and lateral canthus resulting in
dacryostenosis and infection.
Supports significant lower eyelid edema.
Reveals that glasses rest upon the lower eyelid tissues and cause lower eyelid
ectropion as a result of the weight of the glasses and weight of the tissue.
Payment may be considered on an individual consideration basis when
supportive documentation (e.g., the patient's chief complaint and operative
report) is included as part of the patient’s medical record to demonstrate that
the procedure is medically necessary for reconstructive reasons.
C. Relief of eye symptoms associated with blepharospasm (333.81). Primary essential
idiopathic blepharospasm is characterized by severe squinting, secondary to
uncontrollable spasms of the periorbital muscles. Occasionally, it can be debilitating. If
other treatments have failed or are contraindicated (i.e., an injection of botulinum toxin A),
an extended blepharoplasty with wide resection of the orbicularis oculi muscle complex
may be necessary.
Documentation of the following criteria (A, B, C, and D, if applicable) must be met to establish
medical necessity:
A. Patient signs and symptoms that justify functional surgery may include:
1. Interference with vision or visual field, related to activities such as difficulty reading
due to upper eyelid drooping, looking through the eyelashes, seeing the upper eyelid
skin and brow fatigue.
2. Chronic eyelid dermatitis due to redundant skin.
3. Difficulty wearing prosthesis.
4. Chronic blepharitis.
B. Photographs and medical documentation of one or more of the following:
1. Frontal photos are needed to demonstrate redundant skin on the upper eyelids.
2. Upper eyelid skin resting on the eyelashes or over eyelid margin.
3. Upper eyelid indicates the presence of dermatitis, or upper eyelid dermatitis
secondary to redundant skin.
4. Dermatochalasis (ICD-9 code 374.87).
5. The upper eyelid position contributes to difficulty tolerating a prosthesis in an
anophthalmia socket.
6. Also may include:
a. MRD of 2.5 mm or less; the upper eyelid margin approaches to within 2.5 mm
(1/4 of the diameter of the visible iris) of the corneal light reflex.
b. A palpebral fissure height on down-gaze of 1 mm or less. The down-gaze
palpebral fissure height is measured with the patient fixating on an object in
down-gaze with the ipsilateral brow relaxed and the contralateral lid elevated.
c. The presence of Herring's effect meeting one of the above two criteria.
(Herring's law is one of equal innervation to both upper eyelids and is
considered in the documentation to perform bilateral ptosis in which the position
of one upper eyelid has marginal criteria and the other eyelid has good
supportive documentation for ptosis surgery. In these cases, the surgeon can lift
the more ptotic lid with tape or instillation of phenylepherine drops into the
superior formix. If the less ptotic lid then drops downward according to Herring's
law to the point of an MRD of 2.5 mm or less or a down-gaze MRD of 1.5 or less
or a palpebral fissure width on down-gaze of 1 mm or less, then the less ptotic
11
Insurer Content
lid would be considered for surgical correction.)
C. Visual fields testing recorded to:
1. Demonstrate a minimum 12° degree or 30 percent loss of upper field of vision with
upper lid skin and/or upper lid margin in repose and elevated (by taping of the lid) to
demonstrate potential correction by the proposed procedure or procedures. Visually
significant brow ptosis may be documented by visual field testing with the brow
elevated demonstrating a difference of 12° or more or 30 percent superior visual
field difference.
2. Visual fields need to meet accepted quality standards, whether they are performed
by Goldmann technique or by use of a standardized automated technique.
3. Visual fields are not necessary for patients with an anophtholmic socket who are
experiencing ptosis of difficulty with their prosthesis.
D. If a combination of a blepharoplasty and another repair (e.g., ptosis repair or brow lift) are
planned, both must be individually documented.
Limitations:
1. Blepharoplasty done for cosmetic purposes, not meeting the criteria of the functional
visual impairment parameters previously listed, will be denied.
2. When the physician has determined that the patient requires a bilateral blepharoplasty,
bilateral blepharoptosis repair or bilateral brow ptosis repair, it is expected that the
procedures will be performed on the same date of service. Bilateral procedures performed
on different dates of service require documentation in the patient’s medical record to
support the medical necessity of performing these procedures on different dates of
service.
3. External ocular photography (92285) is not payable when used to support the need for
blepharoplasty, blepharoptosis or brow ptosis.
References
Professional society guidelines/other:
Allmed Healthcare Management. White Paper: Eyelid Surgery (Blepharoplasty) & Visual Field Testing:
Medically Necessary or Cosmetic? http://allmedmd.com/resources/Blepharoplasty_WP.pdf. Accessed April
13, 2017.
American Society of Plastic Surgeons (ASPS). Practice Parameter for Blepharoplasty. ASPS, 2007a.
https://www1.plasticsurgery.org/ebusiness4/sso/login.aspx. Accessed April 13, 2017.
American Society of Plastic Surgeons (ASPS). ASPS Recommended Insurance Coverage Criteria for Third-
Party Payers Blepharoplasty. Arlington Heights IL: ASPS, 2007b.
http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/insurance/ASPS-
Recommended-Insurance-Coverage-Criteria-for-Blepharoplasty.pdf. Accessed March 15, 2018.
Cahill KV, Bradley EA, Meyer DR, et al. Functional indications for upper eyelid ptosis and blepharoplasty
12
surgery: a report by the American Academy of Ophthalmology. Ophthalmology. 2011;118(12):2510 – 17.
Christie B, Block L, Ma Y, Wick A, Afifi A. Retrobulbar hematoma: A systematic review of factors related to
outcomes. J Plast, Reconstr & Aesthet Surg. 2018;71(2):155-161.
Prendeville S. Upper eyelid surgery: will Medicare pay? Fort Myers FL: News-Press.com, March 11, 2014.
http://www.news-press.com/story/life/wellness/2014/03/10/upper-eyelid-surgery-will-medicare-
pay/6273801/. Accessed March 15, 2018.
Peer-reviewed references:
Boboridis Kostas G, Bunce C. Interventions for involutional lower lid entropion. Cochrane Database Syst
Rev. 2011;12:CD002221.
Chang S, Lehrman C, Itani K, Rohrich RJ. A systematic review of comparison of upper eyelid involutional
ptosis repair techniques: efficacy and complication rates. Plast Reconstr Surg. 2012;129(1):149 – 57.
Czyz CN, Foster JA, Lam VB, et al. Efficacy of pulsed electromagnetic energy in postoperative recovery from
blepharoplasty. Dermatol Surg. 2012;38(3):445 – 50.
Drolet BC, Sullivan PK. Evidence-based medicine: blepharoplasty. Plast Reconstr Surg. 2014;133(5):1195 –
205.
Hu JW, Byeon JH, Shim HS. Simultaneous double eyelid blepharoplasty and ptosis correction with a single-
knot, continuous, non-incisional technique: a five-year review. Aesthet Surg J. 2016;36(1):14 – 20.
Li J, Lin M, Zhou H, Jia R, Fan X. Double-eyelid blepharoplasty incorporating blepharoptosis surgery for
‘latent” aponeurotic ptosis. J Plast Reconstr Aesthet Surg. 2011;64(8):993 – 99.
Mejia JD, Egro FM, Nahai F. Visual loss after blepharoplasty: incidence, management, and preventive
measures. Aesthet Surg J. 2011;31(1):21 – 29.
Oestreicher J, Mehta S. Complications of blepharoplasty: prevention and management. Plast Surg Int.
2012;2012:252368. Doi: 10.1155/2012/252368. 1 – 10.
Pacella E, Mipatrini D, Pacella F, et al. Suspensory materials for surgery of blepharoptosis: A systematic
review of observational studies. PLoS One. 2016;11(9):e0160827.
Parbhu KC, Hawthorne KM, McGwin G Jr, Vincinanzo MG, Long JA. Patient experience with blepharoplasty.
Ophthal Plast Reconstr Surg. 2011;27(3):152 – 54.
Patrocinio TG, Loredo BA, Arevalo CE, Patrocinio LG, Patrocinio JA. Complications in blepharoplasty: How to
avoid and manage them. Braz J Otorhinolaryngol. 2011;77(3):322 – 27.
13
Pool SM, Krabbe-Timmerman IS, Cromheecke M, van der Lei B. Improved upper blepharoplasty outcome
using an internal intradermal suture technique: a prospective randomized study. Dermatol Surg.
2015c;41(2): 246 – 49.
Pool SM, Struys MM, van der Lei B. A randomized double-blinded crossover study comparing pain during
anaesthetizing the eyelids in upper blepharoplasty: First versus second eyelid and lidocaine versus
prilocaine. J Plast Reconstr Easthet Surg 2015a;68(9):1242 – 47.
Pool SM, van Exsel DC, Melenhorst WB, Cromheecke M, van der Lei B. The effect of eyelid cooling on pain,
edema, erythema, and hematoma after upper blepharoplasty: A randomized, controlled observer-blinded
evaluation study. Plast Reconstr Surg. 2015b;135(2):277e – 81e.
Smith HB, Jyothi SB, Mahroo OA, et al. Patient-reported benefit from oculoplastic surgery. Eye (Lond). 2012;
26(11):1418 – 23.
Yu W, Jin Y, Yang J, et al. Occurrence of bruise, hematoma, and pain in upper blepharoplasty using blunt-
needle vs sharp-needle anesthetic injection in upper blepharoplasty: A randomized controlled trial. JAMA
Facial Plast Surg. 2017;19(2):128 – 32.
CMS National Coverage Determinations (NCDs):
No NCDs identified as of the writing of this policy.
Local Coverage Determinations (LCDs):
A52847 Blepharoplasty – Medical Policy Article. Revision effective January 1, 2018.
L33994 Blepharoplasty (CGS Administrators LLC). Revision effective October 1, 2015.
L34194 Blepharoplasty, Eyelid Surgery and Brow Lift (Noridian Healthcare Solutions LLC). Revision effective
October 1, 2015.
L36286 Blepharoplasty, Eyelid Surgery and Brow Lift (Noridian Healthcare Solutions LLC). Revision effective
October 1, 2015.
L34528 Blepharoplasty, Blepharoptosis and Brow Lift (Wisconsin Physicians Service Insurance Corporation).
Revision effective October 1, 2017.
L34411 Blepharoplasty, Eyelid Surgery and Brow Lift (Palmetto GBA). Revision effective February 26, 2018.
L35004 Surgery: Blepharoplasty (Novitas Solutions, Inc.). Revision effective December 30, 2015.
14
Commonly submitted codes
Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is not
an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and bill
accordingly.
CPT Code Description Comment
15820 Blepharoplasty, lower eyelid
15821 Blepharoplasty, lower eyelid; with extensive, herniated fat pad
15822 Blepharoplasty, upper eyelid
15823 Blepharoplasty, upper eyelid; with excessive skin weighting down lid
67900 Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)
67901 Repair of blepharoptosis; frontalis muscle technique with suture or other
material (e.g., banked fascia)
67902 Repair of blepharoptosis; frontalis muscle technique with autologous
fascial sling (includes obtaining fascia)
67903 Repair of blepharoptosis; (tarso) levator resection or advancement,
internal approach
67904 Repair of blepharoptosis; (tarso) levator resection or advancement,
external approach
67906 Repair of blepharoptosis; superior rectus technique with fascial sling
(includes obtaining fascia)
67908 Repair of blepharoptosis; conjunctivo-tarso-Muller’s muscle-levator
resection (eg, Fasanella-Servat type)
ICD-10 Code Description Comment
G24.5 Blepharospasm
H02.101-H02.109 Unspecified ectropion of eyelid
H02.111-H02.119 Cicatricial ectropion of eyelid
H02.121-H02.129 Mechanical ectropion of eyelid
H02.131-H02.139 Senile ectropion of eyelid
H02.141-H02.149 Spastic ectropion of eyelid
H02.30-H02.36 Blepharochalasis eyelid
H02.401-H02.409 Unspecified ptosis of eyelid
H02.411-H02.419 Mechanical ptosis of eyelid
H02.421-H02.429 Myogenic ptosis of eyelid
H02.431-H02.439 Paralytic ptosis of eyelid
H02.831-H02.839 Dermatochalasis of eyelid
H16.211-H16.219 Exposure keratoconjunctivitis
Q10.0-Q10.3 Congenital ptosis
HCPCS
Level II Code Description Comment
N/A